Outpatient Therapy Social Intake Form PATIENT INFORMATIONChild's Name(Required)Date of Birth(Required) Child's Age(Required)Child's Gender(Required) Male Female Parent/Guardian Name(Required)Relationship to Child(Required)Primary Contact Number(Required)Best Way to Contact You(Required) Phone Email BIRTH & PREGNANCY HISTORYPregnancy Complications None Yes If Yes, explain below:Birth Weight – Lbs, OzType of Delivery Vaginal C-Section Assisted Delivery Complications None Yes If Yes, explain below:NICU Stay None Yes If Yes, how long:Prenatal Exposures None Smoking Alcohol Drugs Other If other, explain: